In our high technology era, the need for a physical examination may surprise the uninformed [Sackett DL. The science of the art of the clinical examination. JAMA. 1992;267:2650–2652; Adolph RJ, Reilly BM. Physical examination in the care of medical inpatients: an observational study. Lancet. 2003;362:1100–1105].
The importance of a systematic history and physical examination is best understood by considering the following points: (1) Attention to the story of the patient’s illness and thoughtful performance of the physical examination (the “laying on of hands”) establish a personal relationship of trust and respect between the patient and the clinician that is necessary for a good medical care. (2) Performing laboratory tests and imaging studies without diagnostic hypotheses generated from the history and physical examination is expensive and often produces false-positive results, delaying proper diagnosis. (3) Conclusions drawn from the results of blood tests, imaging procedures, and even biopsy material are based upon the pretest probability of the various diagnoses under consideration. The pretest probability is derived from the history, physical examination, and knowledge of disease prevalence. (4) In addition, many studies have shown that the history and the physical examination are more sensitive and specific than imaging tests in the most difficult diagnostic situations [Kirch W, Schafi C. Misdiagnosis at a university hospital in 4 medical eras. Medicine (Baltimore). 1996;75:29–40].
We use our four senses to elicit signs of disease: inspection (sight and smell), palpation (touch), percussion (touch and hearing), and auscultation (hearing). Only minimal manual dexterity is required for percussion and palpation. Each physical examination is an opportunity to further train these senses. With reflective practice you will detect changes in structure and function overlooked by an untrained examiner. The physiologic and disease hypotheses generated during the history and the physical examination are tested in the various laboratories leading to precise diagnosis with an economical use of resources.
To become a skillful diagnostician you must constantly reflect on the findings from your examination, the correlations between your examination and the laboratory and imaging studies, and the accuracy of your findings and hypotheses based upon the final diagnoses. In short, you must practice and study. No one started as an expert history taker, physical examiner, or diagnostician. The experts are those who have learned from their experience and refined their senses and skills through repetition and reflection. With experience, you will be able to rapidly assess the severity of illness and the urgency for treatment.
Methods for Physical Examination
Inspection is an observation with your eyes and sense of smell. Among the examination methods, inspection is the least mechanical and the hardest method to learn, but it yields many important physical signs. Because we tend to see things that have meaning for us, inspection depends entirely on the knowledge and expectations of the observer. This is epitomized in maxims such as ...